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Victoria Midwives Protocol - Observations in labour

I have recently been asked about the observations taken during labour by midwives attending homebirth. I can only speak of births that I have been involved in, and midwives with whom I have worked.

The usual practice in Victoria within the Midwives in Private Practice (MIPP) group is to have a second midwife meet the woman and her partner prior to the birth, and attend the birth with the primary care midwife, providing support as needed.

Women who give birth at home are a pretty diverse group, and not all those who would be classified as "low risk" by hospital standards. For example a woman may be considered too old, too short, or too fat to be under midwife care in hospital units. They may have had a previous caesarean section birth. It is my responsibility to advise the woman on the factors in her situation that may increase her need for obstetric intervention, and to make it clear to her under what circumstances I would recommend medical care. The woman may not accept my advice, and this is dealt with in our Code of Practice (Code of Practice for Midwives in Victoria 1996). The big difference between home and hospital care is continuity of care. The midwife and the mother know each other, so observations are of the whole person, as well as T, P, BP, FH &c.

As a rule my observations in labour are:

• Initial set of observations, as on admission in labour in hospital.
• Any observation that causes concern is checked, and advice on appropriate management given. (e.g. an elevated temperature would probably indicate the need for medical referral)
• Vaginal examinations are not routinely done. If there is an indication I will explain this to the woman, who would usually consent.
• T and FH/movements twice daily by me or the mother if the membranes are ruptured and no labour.
• Half-hourly FH, observation of liquor, recording of contractions, and maternal pulse after onset of good labour. This is hard to define, of course. If a woman is having 4'-5' contractions and is active or resting between I may only record observations hourly. Many women will not want the midwife in attendance until late first stage. If we have traveled a distance to the home, and the woman is in early labour we will often remain very much in the background until progress is evident.
• Listen to FH asap after rupture of membranes or change in the pattern of labour.
• I do not routinely check for full dilatation, so I record urges to push, and woman's responses in determining second stage. In second stage I listen to FH about every 10-15 minutes, immediately after a contraction, and listen through a contraction if there is any concern.
• Postnatally observations are fairly informal - ensuring mother and baby are well is top priority. We usually follow physiological third stage, but have oxytocics handy. The cord is usually not clamped or cut until after the placenta is out.
• Small tears are not sutured, and some women prefer to leave second degree tears unsutured. In my limited experience they have healed well, and the women have been very satisfied.
• A set of formal obs are done on both mother and child somewhere in the first hour postnatally. Of course in the home there are no other 'patients' or situations to distract the midwives. We are usually there for 3-4 hours, and check that mother voids well, baby's feeding, and get mother and babe resting together. (FH=fetal heart rate)

Joy Johnston, FACM IBCLC
Independent midwife and lactation consultant
Melbourne, Australia
Joy@aitex.com.au

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